What attitudes do people (professional and lay) have to promotion?

Finding out what people think about promotion, and what effect they think it has on them, is important because it can help us develop educational interventions about promotion. However, research on this topic cannot provide evidence about the actual effects of promotion. Promotion may affect people in ways that they do not know about, or are reluctant to tell others about.

This review describes studies that examine what people think about promotion. Studies about how people use promotion and other sources of drug information are not included here; these can be found in Review 2.

Research on attitudes to promotion relies heavily on survey methods. It tends to provide estimates of how many people agree with or disagree with certain statements, mostly about the appropriateness and effect of various forms of promotion. There are some more complex studies, which attempt to explore other variables associated with different attitudes to promotion. That is, they try to find out what kinds of people have different attitudes to promotion. These studies are more useful.

There is little qualitative research on people’s attitudes to promotion, and this is a major gap. In order to understand people’s attitudes and values more clearly, in-depth interviews are needed. People should be able to talk in their own words about what they think about promotion and how it affects them. Ethnographic research, in which the researcher spends time with doctors and tries to understand how promotion fits into their working lives, would also be useful.


1.1 Attitudes do not necessarily match behaviour

Several studies show that finding out what people think about promotion may not be a good way to predict their behaviour. For example, Peay & Peay’s 1984 paper (3550) suggests a doctor’s view of the worthiness of an information source may not be reflected in how often s/he uses it. Sales representatives and other commercial sources were not evaluated highly, but sales representatives were the most frequent source of first information about medicines, and were one of the most frequently mentioned sources of information needed to prescribe. Other commercial sources were also frequently mentioned as sources of first information about a drug. Similarly, Gambrill and Bridges-Webb found that 56% of the Australian doctors in their study reported that they used sales representatives as a regular source of information, but only 17% ranked them as the most useful (3950). McCue et al. (3540) surveyed GPs, internists and surgeons in North Carolina, about their attitudes toward and use of different sources of information about new drugs. Although only 27.7% of the respondents viewed drug sales representatives as accurate and accessible sources of information about new drugs, they were used more frequently than other sources. This study had a low response rate.


1.2 Studies of the prevalence of different attitudes to promotion (excluding DTCA)

These are studies that simply assess percentages of people who report certain attitudes or beliefs about promotion. Some do start to explore differences within their samples, but this is not their main objective. Many of these studies look at the attitudes of medical students, doctors in training programmes, their trainers, or patients. Few studies look at practising doctors, or at the public in general. Studies are often based at one or two institutions (usually in the US and/or Canada), or are written questionnaires sent to directors of training programmes around the US and/or Canada. Most studies focus on doctors in training or their trainers, examining and discussing what is an appropriate relationship between promotion and training.

Surveys of the prevalence of different attitudes include Hodges (1420) who looked at psychiatry residents, interns and clerks in seven Canadian hospitals, Sergeant et al. (980) who looked at family medicine residents in Ontario, Aldir et al.’s (2720) survey of practising and resident doctors in Northeastern Ohio about their views of promotion, Barnes and Holcenberg’s (1160) survey of medical and pharmacy students at the University of Washington in 1970, Blake and Early’s (700) survey of Missouri patients about their attitudes to gifts given by pharmaceutical companies to doctors, Madhaven et al., (2290) who surveyed West Virginia doctors about their attitude to gifts from the industry, Keim’s (1060) survey of directors of emergency medicine programmes, and residents in these programmes, about their attitude to interactions with the pharmaceutical industry. Others include Mainous et al., (690) who surveyed 649 adults in Kentucky about their attitudes to doctors accepting gifts from the pharmaceutical industry, Reeder et al., (2490) who surveyed all chiefs of US emergency medicine residency programmes, Strang et al. (960) who surveyed Canadian doctors, Lichstein et al. (3650) who surveyed directors of internal medicine residency programmes and Dunn et al. (9550) who surveyed Ontario physicians.

CONCLUSION: These studies do not suggest any clear patterns in attitudes to promotion. Further research would be required to determine if variations in the findings depend on the population surveyed, and on the way questions were asked, who asks the questions, and in what context.


1.3 Do trainers and trainees think sales representatives should be banned during medical training?

Most (71%) psychiatry trainees surveyed by Hodges disagreed that sales representatives should be banned from making presentations in their training programme (1420). Most directors of internal medicine residency programmes (67%) felt that the benefits of sales representatives outweighed the negative effects. Forty-two percent felt that curtailing sales representative interactions with residents would jeopardise company sponsorship of other departmental activities (3650). Of the internal medicine faculty and residents surveyed by McKinney et al. (2480), 52% of faculty and 66% of residents agreed that presentations by sales representatives should be banned at their institutions.

CONCLUSION: Only 3 studies in the database address this question: some trainers and trainees do, others don’t think that sales representatives should be banned, and qualitative studies would be needed to discover their reasons.


1.4 Do doctors think they have enough training to deal with sales representatives?

Seventy percent of psychiatry trainees did not feel they had had sufficient training about interacting with sales representatives (1420). Only 10% of internal medicine faculty and residents surveyed by McKinney et al. (2480) felt they had had enough training for professional interviews with sales representatives. On the other hand, ninety percent of the practising doctors and 87% of the residents in Aldir et al.’s study felt that they had had sufficient training to critically understand information from companies (2720).

CONCLUSION: Only 3 studies in the database addressed this question. In two studies the vast majority indicated they did not have adequate training to interact with reps. However, in another study the vast majority said they had sufficient training to critically understand information from drug companies. This discrepancy may arise from differences in the framing of the questions, eg locating the deficiency in the training vs in the self.


1.5 Do doctors think sales representatives have a valuable role in medical education?

Twenty-nine percent of psychiatry trainees agreed that sales representatives have an important teaching role (although in the text this is described as ‘more than 40%’) (1420). Eighty percent of the US emergency medicine chief residents thought that their residency programme benefited from interactions with sales representatives. Only 6 chief residents indicated very strong opposition to allowing residents to interact with sales representatives (2490). In Bucci and Frey’s study (4430) of US family practice residency programmes, 48.3% of programme directors felt that sales representatives were a valuable drug information resource for residents, and 55.1% felt they were valuable for practising doctors.

In Dunn’s study of Ontario physicians, about 10% of doctors rated ‘pharmaceutical handouts’ as an important or very important CME resource (10.9% of primary care doctors and 12.2% of hospital based specialists) (9550). Hayes et al. (1750) surveyed general practitioners in the UK about their involvement in and attitudes towards industry involvement in CME. They found that most GPs (90%) had had meetings at their practice for which pharmaceutical companies organised the educational content. The characteristic of these which was most disliked, particularly by trainers and those in practice more than 8 years, was the promotional aspect.

CONCLUSION: The studies reported here all ask quite different (and relatively useless) questions. Opinions about the value of sales reps are mixed; again differences may have resulted from the way in which the question was framed, and more research would be needed to clarify this.


1.6 What do health professionals think about the quality of the information provided by sales representatives and advertisements about drugs?

Thirty two percent of the psychiatry trainees surveyed by Hodges agreed that sales representatives provide useful and accurate information on new drugs (25% for established drugs) (1420). Fifty-eight percent of family medicine residents in Sergeant et al.’s study (980) felt that the literature provided by sales representatives was useful.

Ninety-two percent of the Canadian doctors surveyed by Strang et al. (960) felt that sales representatives had product promotion as their major goal, and 80% felt they overemphasised drug’s effectiveness. Forty-seven percent of the doctors in Eaton and Parish’s study (2270) felt that they were not able to obtain an unbiased assessment of a newly introduced drug. Most of these felt that most drug information was too commercial and therefore biased.

In a New Zealand study, Thomson et al. (2840) found that 58 out of a sample of 67 doctors saw sales representatives. In response to an open-ended question about why, 56 of them gave a reason related to learning about new or existing products. The director of the Pharmaceutical Manufacturers’ Association of New Zealand described a survey of doctors, in a letter to the editor of the New Zealand Medical Journal (6200). Without giving methodological details, he claimed that most NZ doctors felt that sales representatives are a good source of information about drugs and recognise practitioners’ information needs, but are over-biased toward their own products.

In contrast, only 16% of UK GPs surveyed by Hayes et al. found visits by sales representatives to be educationally valuable (1750). University and community practice doctors surveyed by Shearer et al. (3380) rated direct mail, journal advertising and detail men as the three least reliable sources of drug information. Doctors in community hospitals ranked the reps they saw higher than university hospital doctors ranked those reps whom they saw. Whelan et al. (15100) report that staff members in a family medicine residency training programme in Canada did not rate sales representatives as a very useful source of information in response to drug information questions. They rated them poorly on all dimensions: frequency of use, availability, ease of use, understandability, helpfulness, extensiveness, and how much confidence they had in them. Among Cockerill and Williams’ Ontario pharmacists, a minority of the respondents (25%) said sales representatives were an important source of information, while only 17% thought advertisements and promotional literature were. Drug sales representatives were never mentioned as sources of information for the complex clinical case studies used by Boerkamp et al. (3890). The majority of psychiatrists shown advertisements for psychotropics by Lion et al. (21860) did not find them attractive or informative.

Sixty-eight percent of doctors working in a Turkish city surveyed by Güldal and Semin (21520) thought the information provided by representatives was unreliable. Ninety-four percent felt a reliable source of information about drugs, other than drug companies, was needed.

Benseman (6540) found that the 45 New Zealand doctors he surveyed expressed varying degrees of anger and frustration at the waste involved in the material they were sent by drug companies. Almost all felt that drug company material was biased and should not be taken at face value. However they preferred drug company sponsored journals to academic journals, because they found them more relevant to general practice.

Mackowiak et al. (21840) surveyed a small convenience sample of US community pharmacists and a small sample of pharmacy students about advertisements for over the counter drugs in pharmacy journals. In the US, advertisements for over the counter medicines are regulated by the Federal Trade Commission. They must be truthful and not misleading. This is a lower standard than that enforced for prescription drugs. Around half the pharmacists, and students, surveyed by Mackowiak regarded the advertisements they were shown as misleading and not truthful. However they also reported high levels of reliance on them. Most respondents (90% of pharmacists and 81% of students) thought regulations for over the counter products should be the same as prescription products.

In a study of health care providers in Africa (16820), commissioned by the International Federation of Pharmaceutical Manufacturers’ Associations and the US Pharmaceutical Manufacturers’ Association, 95% of those who received company-provided information reported finding it helpful. The design of this study is not well described.

CONCLUSION: Doctors’ opinions on the usefulness of information from drug companies vary but most believe that such information is biased.


1.7 What do other groups of people think of promotional information?

Journalists who wrote about medicines claimed to be critical of material from the drug industry in a study by van Trigt et al. (830). Companies were not considered important sources for drug information in general, but the manufacturer was seen as a major source of information when a new drug was registered or became available.

CONCLUSION: Only one study in the database addresses this question. More research is needed.


1.8 What are doctors’ views of pharmaceutical company support of conferences and speakers?

Most of the psychiatry trainees surveyed by Hodges (1420) (77%) agreed that sales representatives support important conferences and speakers. Most family medicine residents surveyed by Sergeant et al. (980) agreed that the content of CME activities should be set by the doctors organising them, rather than the company sponsoring them.

CONCLUSION: Only two studies in the database address this question. More research is needed.


1.9 Do trainee doctors plan to see sales representatives in their future practice?

Most (76%) family medicine residents in one Canadian centre surveyed by Sergeant et al. planned to see representatives in their future practice (980). A significant minority (42%) of the Canadian psychiatry trainees surveyed by Hodges (1420) said they would not maintain the same degree of contact with sales representatives if no gifts were distributed.

CONCLUSION: Only two Canadian studies from 1994 and 1996 address this question. Data from recent graduates would be useful.


1.10 What are professionals’ and patients’ attitudes to the appropriateness of gifts?

Most (55%) of the family medicine residents surveyed by Sergeant et al. said they would attend a private dinner with a sales representative paid for by a company. Thirty-six percent felt that gifts from sales representatives to doctors resulted in higher drug costs for patients (980). The doctors surveyed by Aldir et al. felt that smaller gifts were more appropriate than more valuable ones (2720). Of the Canadian doctors surveyed by Strang et al. (960) 85% agreed that sales representatives should be able to offer free samples, but 74% felt they should not be able to offer all-expenses-paid trips to meetings organised by companies.

More than half of the residents surveyed by Keim et al. (1060), reported accepting gifts such as textbooks because they needed financial assistance with their education. Seventy-eight percent of programme directors and 92% of students believed it was appropriate to accept textbooks from drug sales representatives. Keim et al. found that those who were more sensitive to bioethical issues in general were less willing to accept non-educational gifts. Twenty-five percent of resident doctors in Virginia surveyed by Sigworth et al. (21390) said they would not want patients to know they had received gifts and awards from drug companies and would try to hide this.

In a simple but clever research design, Palmisano and Edelstein (3470) asked 100 medical students and 100 family planning nurses about the propriety of various people accepting gifts. Of the 50 medical students who were asked, 85.4% felt it was improper for a government official to accept a $50 gift from someone who wanted to gain a contract. Of the other 50 students, 46% felt it was improper for a medical student to accept a $50 gift from a drug company. The nurses were divided into three groups and asked different versions of the question. Of those who were asked, 97% felt it was improper for the government official to accept the gift, 64% felt it was improper for a resident doctor to accept the gift, but only 30% felt it was improper for a nurse practitioner to accept the gift.

Amongst the Turkish doctors surveyed by Guldal and Semin, (21520) 33% felt that gifts were not ethical, 36% felt they were not ethical in some respects, and 21% felt that gifts were ethical.

Sixty four percent of the patients surveyed by Blake and Early (700) believed that gifts would increase the costs of medicines. They approved more of doctors accepting some gifts like drug samples, medical books, ballpoint pens, and conference expenses, than others like dinners, baby formula, and golf tournaments. Men, older people and those with tertiary education were more likely to disapprove of gifts. They were more likely to disapprove of gifts (except free samples) if they felt that they influenced prescribing and increased cost. One limitation of this study was that many patients were unaware that such gifts were given, so had little time to consider their opinion of them while completing the questionnaire. In Mainous et al.’s Kentucky study (690) many more people (82%) were aware that doctors received office based gifts than personal gifts (32%). This study used a population-based sample, rather than a practice-based sample. Substantial minorities of people felt that gifts had a negative effect on health care costs (42% for personal and 26% for office gifts) and health care quality (23% for personal and 13% for office gifts). These beliefs were more common amongst respondents with higher levels of education.

Gibbons et al. (3790) asked doctors and patients about the same list of ten gifts, and found that patients rated the gifts as less appropriate and more likely to influence prescribing, than doctors did. Those with higher levels of education (i.e. those who had completed high school) were more likely to think that the cost of gifts was passed on to patients. Before the survey about half of the patients (54%) were aware that doctors accepted such gifts. Of those who were previously not aware of this, 24% said that learning about them had changed their perception of the medical profession.

CONCLUSION: Seven studies in the database address the question of professionals’ attitudes to gifts. The studies available suggest that there is a range of views about gifts but a tendency for gifts that were smaller or more relevant to helping patients to be regarded as more acceptable. There is evidence that professionals believe that their acceptance of gifts goes below community standards and their own standards for other people in positions of responsibility.

Three studies in the database address the question of lay peoples’ attitudes to gifts. The studies available suggest only a minority are aware that doctors receive personal gifts, so only a minority disapprove, but people with higher levels of education were more likely to disapprove.


1.11 Do health professionals feel that discussions with sales representatives affect prescribing?

Thirty-five percent of the psychiatry trainees in Hodges’ study (1420) agreed that discussions with sales representatives did not influence their prescribing behaviour. This attitude was less prevalent amongst more senior trainees. Amongst the Canadian family medicine residents in the Sergeant et al. (980) study 34% agreed and 43% disagreed that sales representatives influenced their prescribing habits. In emergency medicine, Keim et al. (1060) found that 75% of programme directors, but only 49% of residents, believed that marketing techniques affect resident prescribing practices. Seventy percent of the Canadian doctors surveyed by Strang et al. (960) agreed that sales representatives affected physicians’ prescribing habits. Thirty-one percent of the internal medicine residency programme directors surveyed by Lichstein et al. were concerned, and 13% were very concerned, about the impact of sales representatives on the attitudes and prescribing behaviours of their residents (3650). Most directors of family practice residency programmes in the US (56%) felt that the information and resources provided by sales representatives affected the prescribing of residents and practising doctors (4430).

Bansinath et al. (5780) state that only 5-6% of Indian cardiologists report that medical sales representatives had played a role in their decisions to prescribe brand or generic drugs. Sixty-three percent of doctors in a Turkish city, surveyed by Guldal and Semin (21520) felt that information from sales representatives did not influence their prescribing. Those who found information from sales representatives reliable tended to report that this information had more influence on them.

American general practitioners surveyed by Pitt and Nel (10380) rated sales representatives as the third most important influence on their prescribing decisions, advertisements as fifth and gifts as sixth. However, this study had a low response rate and excluded journal articles in the list of possible influences. Clinical pharmacists involved in family medicine residency programmes, surveyed by Hume and Shaughnessy (12710), rated sales representatives, along with journal articles, as the third most important source of drug information influencing the prescribing of family medicine residents.

In Sigworth et al.’s (21390) study of resident doctors in Virginia in 2000, 91% reported that sales representatives had some effect on their prescribing. The authors suggest that this high rate could be the result of recent publicity and discussion on these issues, although these residents had not had formal educational sessions on drug promotion.

CONCLUSION: Many doctors denied that they were influenced by drug reps: in three studies of residents 34, 49 and 91% believed they were affected, in three groups of programme directors 75, 31 and 56% did so. The available data suggest that doctors may be more willing to say that other doctors are influenced than they are themselves, but this remains a hypothesis.


1.12 Do people feel that accepting gifts influences prescribing?

Most (56%) of the psychiatry trainees surveyed by Hodges felt that accepting gifts did not influence their prescribing (1420). In the Aldir et al. study (2720) few doctors thought that a gift of a textbook influenced prescribing habits (less than 6%). Similarly they felt that lunches or dinners provided by the industry had little influence on them, although they did feel that free samples affected their prescribing. In Barnes and Holcenberg’s study, 60% of medical students and 75% of pharmacy students felt that promotional practices influenced prescribing (1160). Patients surveyed by Blake and Early (700) also felt that gifts from the pharmaceutical industry to doctors were likely to influence prescribing (6% said it never did, 18% said rarely, 43% sometimes, and 16% frequently). They were more likely to disapprove of gifts (except free samples) if they felt that they influenced prescribing and increased cost. One limitation of this study was that many patients were unaware that such gifts were given, so had little time to consider their opinion of them while completing the questionnaire.

Eighteen percent of the Turkish doctors in Guldal and Semin’s study (21520) felt that gifts strongly affected prescribing, 12% felt they had a medium effect, 44% low, and 27% felt they had no effect on prescribing.

Madhaven et al. (2290), found that physicians were more likely to think that other doctors prescribing was influenced by gifts, than that their own was. They also found doctors with more patients were less likely to agree that most doctors are influenced by gifts and less likely to think it is inappropriate to accept gifts.

Banks and Mainous (3620) surveyed medical school faculty at the University of Kentucky. Of a list of gifts given by sales representatives, none were seen as influencing prescribing by more than half of the respondents, although personal relationships with sales representatives were seen as influencing prescribing by 66% of faculty. PhD staff were more likely than MD staff to think that gifts influenced prescribing, and to oppose the acceptance of gifts. Most internal medicine faculty and residents surveyed by McKinney et al. (2480) felt that doctors could be compromised by accepting gifts (67% and 77%). However some (23% of faculty members and 15% of residents) believed that doctors could not be compromised regardless of the value of the gift received. In Cockerill and Williams’ (16450) survey of Ontario pharmacists 50% felt there was a conflict of interest in accepting benefits from the drug industry. Those licensed after 1980 were less likely to think so.

CONCLUSION: In most studies most doctors denied that they were influenced by gifts. The available data suggest that doctors may be more willing to say that other doctors are influenced than they are themselves but this hypothesis deserves more research. The only study on patients’ attitudes found they were more likely to disapprove of gifts (except free samples) if they felt that they influenced prescribing.


1.13 Ethics and Promotion

Seventy-four percent of the emergency medicine residents surveyed by Keim et al. (1060) felt that sales representatives sometimes crossed ethical boundaries by giving gifts. Fourteen percent of internal medicine residency programme directors reported observing unethical activities by sales representatives (1060). These included detailing in clinical areas, making false claims, giving monetary gifts, and conducting unauthorised studies.

A study by Poirier et al. (3930) of people who make decisions about formularies in US private hospitals, found that most (93%) felt that providing non-monetary benefits to doctors to influence formulary decisions or product use was unethical. The respondents included chairs of pharmacology and therapeutics committees, directors of pharmacy, and pharmacists involved in evaluating drugs for inclusion in formularies. More pharmacists than doctors rated providing meals to influence decisions as unethical (22% versus 12%).

A US study by La Puma et al. (890) examined payments to doctors to participate in post-marketing research on new medicines. Most of the doctors they surveyed (64%) felt it was acceptable to be paid a fee for each patient enrolled in post-marketing research. Most patients (56%) felt this was unacceptable. Fewer doctors than patients felt that patients should be informed if the doctor was being paid a fee per patient enrolled (75% versus 86%).

CONCLUSION: Only four studies have addressed this issue and each of them looked at different aspects of the question, making it hard to draw any conclusions. From one study it appears that doctors think that it is more ethical to accept fees for enrolling patients in clinical trials than do patients.


1.14 Attitudes to direct-to-consumer advertising of prescription drugs (DTCA)

Since the introduction of direct to consumer advertising of prescription medicines (DTCA) in the USA in the 1980s, there have been phenomenal increases in spending on it. One estimate was that in 1999, US$1.6 billion was spent on DTCA (15410).

a. Doctors

Petroshius et al. (3170) describe the results of a questionnaire delivered to doctors (general practitioners, family practitioners, internists and dermatologists) by sales representatives as part of their normal visits. They found older doctors and internists to be less supportive of advertising of drugs and cosmetic drugs than other doctors. This was especially the case with DTCA. Those over 50 had a negative response to DTCA (mean response was 2.84 on a scale from 1 for strongly agree, to 5 for strongly disagree). The authors found that doctors’ attitudes towards DTCA were good predictors of whether they paid attention to such advertisements and how they said they would respond to patient enquiries and requests for advertised drugs. This study obviously excluded doctors who do not receive sales representatives.

Cutrer and Pleil found largely negative attitudes towards direct to consumer advertising (DTCA) of prescription medicines amongst the Texas doctors they surveyed (4180). However their response rate was very low (17%). Doctors felt that DTCA would increase the demand for drugs, and increase questioning by patients.

Lipsky and Taylor (3180) surveyed a 2% sample of active members of the American Academy of Family Physicians about their attitudes to DTCA. Doctors reported an average of 6.9 patients in the last six months who requested a specific prescription drug, although the article is not explicit about whether doctors were asked specifically about requests that resulted from DTCA. Eighty percent of those surveyed were opposed to print DTCA and 84% opposed to broadcast DTCA. While there was some agreement about possible positive outcomes of DTCA (56% agreed that it encourages patients to seek medical advice for conditions that may otherwise go untreated, and 73% that it alerts patients to new products), there was also consensus about possible negative outcomes (89% disagreed that DTCA enhances the doctor-patient relationship, 71% agreed that DTCA pressures doctors to use drugs they might not ordinarily use, and 72% felt DTCA discourages the use of generics).

CONCLUSION: Doctors are largely opposed to DTCA advertising.


b. Consumers

Lipton, a public relations executive from the US, reports on a survey of consumers’ attitudes to DTCA (2390). The methodology of the study is not described. Half of the people thought that DTCA would provide them with more information about prescription drugs. Those who were better educated, younger, and those with higher incomes were less likely to feel that DTCA would increase their knowledge about specific drugs.

Bell, Kravitz and Wilkes (22040) surveyed 329 adults in Sacramento, California, about their awareness, knowledge and attitudes to DTCA. They asked whether people remembered advertisements for 10 different drugs, and found recognition varied between 8% and 72% for different drugs. Men reported seeing fewer advertisements than women. There was greater awareness of advertisements amongst sufferers of the conditions treated by the advertised medicines. More positive attitudes to DTCA were correlated with greater awareness of DTC advertisements. The authors found significant public misconceptions about the regulatory framework for DTCA. Fifty percent of respondents believed that DTC advertisements had to be submitted to the government for prior approval, 43% thought that only completely safe prescription drugs could be advertised to consumers, 21% thought that only extremely effective drugs could be advertised to consumers, and 22% thought the advertising of prescription drugs with serious side effects was banned. None of these beliefs are true. People from minority ethnic groups were more misinformed than whites. Positive attitudes towards DTCA were positively correlated with these misconceptions.

‘Prevention’ magazine carries out regular surveys which include consumers’ knowledge or and attitudes to DTCA. Telephone interviews with a representative sample of 1,222 adults in the US were described in the 2000/2001 report [update of (15410)]. Lower levels of awareness of DTCA advertising (ie, reporting ever having seen a DTC advertisement) were found amongst ethnic minorities, low-income consumers, and those not taking prescription medicines. Ninety one percent of respondents reported having seen an advertisement for at least one of ten highly advertised medicines (such as Claritin, Xenical). Fifty-seven percent of consumers thought DTCA gave them the necessary information to ask their doctors about the risks of the medicines (62% for asking about benefits).

Magazine Publishers of America (21300) surveyed allergy sufferers in the US. In their sample, 34% had seen advertisements for allergy medicines in magazines, while 36% had seen such advertisements on TV. Nineteen percent were able to identify the brand for advertisements in each medium. Since less is spent on magazine advertising than TV advertising, the authors argue that advertising in magazines is more cost-effective. They also report that the perceived believability of advertisements for medicines has declined since restrictions on DTCA were loosened in 1997.

Maddox and Katsanis (3250) surveyed consumers in a Canadian city that was exposed to DTCA advertising from the US. They constructed two scenarios involving a fictitious drug. Patients who were given the scenario where they heard about the drug through DTCA, asked their doctor for it, and received a prescription were more confident in their doctors than those whose scenario was that they heard about the medicine from their doctor first. This study had a rather low response rate, and the discussion and conclusions include assertions that do not appear to be justified by the findings.

Rockwell describes the attitudes of a sample of viewers of a US cable TV channel (2370). He is the president of this channel, which shows programmes intended for and advertised to health professionals. Advertisements for prescription drugs were shown during these programmes since 1983. The programmes proved to be popular with the general public who subscribed to this channel. A survey of the non-professional viewers of these programmes found that 95% of them thought DTCA would make patients aware that useful treatments exist. Rockwell suggests that negative public attitudes to DTCA found in other studies are a result of fear of the unknown, but those who have been exposed to DTCA are positive towards it. However it seems untenable to assume that people who watch programmes intended for health professionals are representative of the general population.

Alperstein and Peyrot (3190) surveyed 440 people in Baltimore. They found a moderate level of awareness of DTC advertising. Thirty-five percent of people had heard of prescription drug advertising, and given a prompt, 42% were aware of advertisements for Seldane (an antihistamine). Most respondents felt that DTCA could help educate consumers (70%), while a minority agreed with possible objections to DTCA. Twenty-eight percent felt it would confuse consumers, 21% that asking for an advertised product would upset a doctor, and 12% that DTCA would weaken the doctor-patient relationship. Respondents of higher socio-economic status were more aware of DTCA advertising. Those who were more aware of the advertisements were less likely to believe that the doctor should be the sole source of information about drugs, that DTCA would confuse consumers, and that it would weaken the doctor-patient relationship.

CONCLUSION: Most of the available studies report mostly positive attitudes to DTCA amongst consumers. The apparent positive attitudes could have resulted from the ways the questions were framed or the population sampled. Social and educational differences seem to influence acceptance of DTCA: the less educated may accept it more readily.


c. Others

Mintzes and colleagues (21480) surveyed experts in New Zealand, the United States and Canada, on their views of DTCA, and the evidence that supported these views. (DTCA is allowed in the US and New Zealand, and Canadians are exposed to significant cross-border broadcast DTCA). The experts included people from health professional organisations, non-governmental organisations, government, the pharmaceutical industry, advertising and the media. Opinions about DTCA were divided by sector. Those from the pharmaceutical and advertising industries were overwhelmingly positive, patient representatives showed a lesser degree of support, and other experts had negative opinions of DTCA. Most respondents felt that the information DTCA provided about drug risks and benefits was poor. Respondents felt DTCA increased expenditure on medicines, but beliefs about the impact on doctor-patient communication varied according to sector.

In another study, most of the 97 Canadian Drug Directorate personnel surveyed (18530) believed that more prescription drug information was needed for consumers, but only a quarter of these thought advertising was an appropriate mechanism for this.

Amonkar and Lively (21250) surveyed pharmacists in one Ohio county. Their study achieved a low response rate. Forty-two percent of respondents did not think DTCA on television was beneficial to consumers. Although most (75%) thought that advertising may inform patients about available treatments, and some (32%) thought it may improve patient-pharmacist contact, most (90%) felt there should be prior review of advertisements by an independent panel, and most (87%) felt advertising would probably lead patients to pressure doctors to prescribe advertised drugs.

CONCLUSION: Surveys of experts’ beliefs about DTCA suggest that the beliefs expressed depend on what sector the expert belongs to, with industry experts expressing positive beliefs, patient advocates having mixed beliefs and medical experts having negative beliefs.


1.15 Studies of differences in attitudes to promotion (excluding DTCA)

Peay and Peay’s 1984 study (3550) found two reasonably clear patterns amongst doctors. Those who reported using journals as important information sources evaluated journals more highly and commercial sources lower than other doctors. Those doctors who reported using commercial sources rated these more highly and journals lower than other doctors. There was a group of about 15% of doctors who consistently and exclusively relied on commercial sources of drug information. Those who cited sales representatives as providing information needed to prescribe medicines were older, and those who cited journals were younger.

Although Linn and Davis’s study (1900) was done in 1969-70, there is no reason to believe that the findings are not still relevant. Linn and Davis found that doctors who preferred to use medical journals as a source of advice had more conservative attitudes in other areas, than those who preferred sales representatives or other doctors. The former were less positive about the use of non-medical sources of advice (such as friends and family), and the use of medicines in response to daily social stress.

Amongst the New Zealand doctors surveyed by Thomson et al. (2840) those who reported peer advice being less readily available reported seeing more sales representatives. Cockerill and Williams (16450) surveyed Ontario pharmacists and found that 60% of them placed no restrictions on visits from sales representatives. However those who became licensed after 1980 were more likely to have restrictions. Andaleeb and Tallman (3110) surveyed doctors in four teaching hospitals in Pennsylvania and found that doctors who treated a higher volume of patients were more positive towards sales representatives. They were also more likely to think they provided informational and educational support. This study had a low response rate. Stinson and Mueller (3910) carried out a survey of Alabama health professionals, which included 309 doctors as well as other health professionals. They found that doctors with more years of professional experience reported using sales representatives and unsolicited medical literature more often than others, and that general or family practitioners reported using them more than other specialists.

Evans and Beltramini (1990) found in their survey that respondent GPs were more likely to solicit information about prescription drugs from sales representatives than specialists were, and that older doctors were more likely to use sales representatives for information than younger doctors. Overall the doctors they surveyed preferred non-industry sources of prescription drug information. This study had a low response rate, and response bias was not assessed.

County doctors in Oppenheim et al.’s study (3630) tended to rely more on sales representatives as a source of information on prices, compared to other doctors; county physicians and faculty members had limited knowledge of drug prices and tended to overestimate them. Miller and Blum also found that doctors had limited knowledge of the price of advertised prescription medicines (2550). This study of doctors attending a continuing medical education event had a low response rate.

Santell et al. (21880) surveyed hospital pharmacy directors and sales directors of pharmaceutical manufacturing firms about the role of sales representatives in hospitals. The response rate was low, particularly for the sales directors. Most sales directors thought that sales representatives met the needs of hospital pharmacists more than 80% of the time, but most hospital pharmacy directors thought they were met less than 61% of the time. There was disagreement both about what services were important and how often they were provided.

Hull and Marshall (2470) report on an international study of GPs’ sources of drug information. They claim that sales representatives are seen as very important in Sweden, Finland and Yugoslavia and not important in the UK and Belgium. There are very low numbers in the study, and no details are given about the selection process, so the results should be viewed with a great deal of caution. However, the study raises the important issue of potentially large national differences in attitudes to promotion, which should be taken into account when designing interventions.

CONCLUSION: Doctors appear to fall into different groups with regard to the most used sources of drug information. The available evidence suggests that those who rely more on information from industry tend to be older, less conservative, see more patients, are generalists rather than specialists, have less access to peer support and more positive attitudes to the use of drugs. However most of those findings lack confirmatory evidence from more than one study.

Future Directions for Research

This review presents evidence about people’s attitudes to promotion. This includes whether doctors believe that promotion affects their prescribing. Some studies consider this as evidence of the impact of promotion (2720), but this is incorrect. The evidence in this review could be useful in designing interventions, but should not be used to describe the effects of promotion.

The main limitations of the studies presented here are an over-reliance on survey methods, on the use of convenience and accessible samples, and on describing the prevalence of attitudes rather than exploring their inter-relationship or relationships between attitudes and other characteristics. Qualitative studies are needed in this area.

Survey methods are extremely useful in finding out factual information about a group of people but are of less use in understanding how people think about issues, such as drug promotion. Many of the studies in this review seem to rely on participants who are easily accessible to researchers, rather than being guided by research questions. This has led to an over-emphasis on the views of trainee doctors, and their trainers, as opposed to practising doctors; and the inclusion of patients more often than the general public. Some authors suggest that it is important to study doctors in training because this is where their attitudes are formed. However it seems more likely that this emphasis results simply from convenience. In addition, the studies described here tend to rely on small samples, and many studies have been conducted in one or two institutions. These are unlikely to represent doctors and patients in general. Some of this research also suffers from low response rates (e.g. 1990, 2290)

Qualitative research, exploring in more depth people’s feelings and beliefs about drug promotion would be an important step forward. We need to move beyond simple surveys of attitudes to more sophisticated understandings of how people react to promotion, and how they understand their own reactions. Cognitive and social psychology may be able to make important contributions in this area. For example, some studies suggest that doctors are more likely to think that ‘doctors in general’ are influenced by promotion than they are themselves. This may be similar to other situations in which individuals sometimes regard themselves as less vulnerable to a hazard (such as HIV) than other members of a similar group. Research is needed to explore this further: why and in what ways do doctors think they are invulnerable to promotion, how do they explain their own and others’ vulnerability or lack of it? This points to a general need for research on promotion to learn from other disciplines and research on other topics. Attitudes to promotion should be seen as a specific case of other more general phenomena.

Qualitative research could also help to explore what survey respondents mean when they say that they or others are ‘influenced’ by promotion. Do they include informed (ie a positive meaning) or do they interpret the question to mean ‘unduly’ or ‘negatively’ influenced?

Ethnographic research, which examines medical sub-cultures, would also be extremely helpful in exploring attitudes to promotion. It appears that doctors vary substantially in their views of, and use of promotion. How do these differences come about? What underlies them? Do they reflect overall different political and social views? Are they reflected in different social organisations (such as professional organisations, social networks, etc)? What brings about changes in these values? Do doctors move between them during their working lives? What factors enhance or impede this movement?

 

See Index | Date Entered : Monday, June 02, 2003